febrile

Episode #1 – You’ve got some ex-spleen-in’ to do

1 Cover Art OPT

Summary

Which infections jump to mind in the setting of asplenia?  Join our guest, Dr. Wendy Stead, as she walks through her approach to sepsis in a patient with purpura fulminans and history of splenectomy.

Credits

Host(s): Sara Dong, Jeff Larnard

Guest: Wendy Stead

Writing: Sara Dong, Jeff Larnard

Producing/Editing/Cover Art/Infographics: Sara Dong

Our Guests

Guest Consultant

Wendy Stead, MD

Wendy Stead

Dr. Stead is the program director of the Beth Israel Deaconess Medical Center (BIDMC) Infectious Diseases Fellowship and an Assistant Professor of Medicine at Harvard Medical School. Dr. Stead completed her Internal Medicine residency and ID fellowship at BIDMC and then joined the BIDMC faculty with a joint appointment in the Divisions of Infectious Diseases and General Medicine and Primary Care in 2003. She also completed a Rabkin Fellowship in Medical Education in 2010. She dedicates herself to patient care, medical education, and curriculum development work at the residency and fellowship levels, winning many awards for teaching, mentorship, and humanistic care.  Her active research interests include examining the effects of interdisciplinary education strategies on collaboration between specialty services, communication skills in patients with opioid use disorders, trainee wellness, and gender bias in academic medicine. She also loves narrative medicine and writing stories about her inspiring patients (check out a Piece of her mind here, here, and here or her poetry here)

Guest Co-Host

Jeff Larnard, MD

For better or worse, I am very Massachusetts. I grew up in Amesbury, MA and went to Umass Amherst to study nutrition before going on to Umass Medical School. I had a brief stint in NYC for Internal Medicine residency at Columbia before coming back to Boston to be an Infectious Disease fellow at Beth Israel Deaconess (BIDMC).

My interests include medical education, antimicrobial stewardship, and getting as many pop culture references as possible into presentations and materials. Outside of medicine I love cooking (though maybe not as much as Sara…), running, and enjoying Tom Brady.

Culture

Wendy’s recommendation: David Sedaris‘ When You Engulfed in Flames, essay “That’s Amore”

Consult Notes

Consult Q

Petechial rash concerning for purpura fulminans, assistance with antibiotics and work-up

One-liner

60 year-old male with history of immune thrombocytopenic purpura, prior splenectomy in setting of bleeding (secondary to ITP), and gallstones s/p cholecystectomy who presented with a rapidly progressive purpuric rash/purpura fulminans, septic shock, and disseminated intravascular coagulation.

Key Points

Capnocytophaga

Capnocytophaga Pearls

Fever in a patient with impaired splenic function (asplenia or hyposplenia) is a medical emergency.  The list of causes of asplenia/hyposplenia is long and includes:

  • Iatrogenic (e.g. surgical splenectomy)
  • Hematologic disease or malignancy
  • Vascular thrombosis
  • Autoimmune disorders
  • Infiltrative disease (amyloidosis, sarcoidosis)
  • Gastrointestinal/hepatic disease
  • Congenital syndromes

Is there a difference in risk in someone who has anatomic asplenia vs functional or partial hyposplenism? Is there a ballpark number you can counsel your patients with when thinking about the relative risk when asplenic vs. their normal spleen-ed neighbor? 

Key pathogens to consider with asplenia!

  • Encapsulated bacteria
      • **S.pneumoniae, estimated to account for 40-60% of severe cases but has declined with vaccination
      • H.influenzae type b, which has also declined with vaccination
      • Neisseria meningitidis: less common (prob <3%)
  • Capnocytophaga spp: C.animorsus, C.cynodegmi; dog bites
      • Estimated 12% of reported cases in asplenic pts
  • Bloodborne parasites
      • Malaria
      • Babesiosis
  • Bordetella holmesii: respiratory pathogen that causes pertussis-like sxs in immunocompetent pts but knowledge is limited

How to counsel a patient about asplenia (e.g. pre-splenectomy outpatient visit)

Educating patients and families about the lifelong risk of infection with asplenia is critical.  Your counseling should emphasize strategies to minimize risk.  The keys to remember are:

  • Increased lifelong risk of severe infection
  • Importance of vaccination (see details below)
  • Use of emergency antibiotic prophylaxis
  • When to seek medical care
    • Patients should seek medical care with fever or evidence of systemic infection 
    • Would also counsel on need to seek immediate care for animal bites or tick bites in endemic areas
    • Lastly, patients should be evaluated for pre-travel counseling when needed, especially if expected to travel to malaria endemic region

What are the key vaccinations for patients with asplenia?  Vaccines focus on the organisms of concern with asplenia!  You can use “2-2-1” to remember: two Strep pneumoniae, two N.meningitidis, one HiB:

    • PCV13, followed by PPSV23 8 wks later
    • HiB
    • MenACWY and MenB series
    • Seasonal influenza
    • As always, would also recommend age-appropriate vaccinations

Ideally would administer vaccines as soon as possible.  If the patient is planned for surgery, would try to avoid the 14 days before and after operation due to concern for inadequate antibody response to vaccination in that timeframe.

Here is a paper summarizing vaccination recommendations: 

Check out the CDC Table 2. Recommended Adult Immunization Schedule by Medical Condition and Other Indications, United States, also reproduced below:

What antibiotic prophylaxis should you recommend?

  • Antibiotic prophylaxis can reduce risk of infection and poor outcomes in patients with asplenia
  • All patients should receive empiric emergency antibiotics, often known as “pill in pocket”.  These are on hand for development of fever or other signs of systemic infection.
    • Choice of antibiotic = Amoxicillin-Clavulanate in adults and children
    • Alternate options for penicillin allergic: fluoroquinolones (Levofloxacin or Moxifloxacin), cefdinir
  • Can consider prophylaxis prior to procedures with increased risk of encapsulated organism infections, such as sinus and respiratory tract, in some situations

Other miscellaneous mentions and notes

Episode Art & Infographics

Goal

Listeners will be able to form comprehensive differential diagnosis for overwhelming post-splenectomy sepsis

Learning Objectives

After listening to this episode, listeners will be able to:

  • Identify Capnocytophaga as cause of sepsis and purpura fulminans in asplenic patients
  • Recognize fever in a patient with impaired splenic function is a medial emergency
  • Identify key pathogens that lead to infection in asplenic or hyposplenic individuals
  • List the key vaccinations indicated for patients with asplenia
  • Describe the appropriate patient education to provide when counseling patients with asplenia

Disclosures

Our guest (Dr. Wendy Stead) as well as the Febrile Podcast and hosts report no relevant financial disclosures.

Citation

Stead, W., Dong, S., Larnard, J. “#1: You’ve got some ex-spleen-in’ to do”. Febrile: A Cultured Podcast.  https://player.captivate.fm/episode/9accbc32-9994-4592-b2cc-55c0260dbb64

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